Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Sunday, January 17, 2016

Not Going to Take it Anymore - Doctors in the Pacific Northwest Unionize, Begin Collective Bargaining with Hospital Systems

We have posted about the plight of the corporate physician. In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit. The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.

We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management.
Managerialism wraps these concepts up into a single package. The idea
is that all organizations, including health care organizations, ought to
be run people with generic management training and background, not
necessarily by people with specific backgrounds or training in the
organizations' areas of operation. Thus, for example, hospitals ought
to be run by MBAs, not doctors, nurses, or public health experts.
Furthermore, all organizations ought to be run according to the same
basic principles of business management. These principles in turn ought
to be based on current neoliberal dogma,
with the prime directive that short-term revenue is the primary goal.

Now there are a few signs that the physicians are getting fed up with having to answer to generic management and managerialism.

I found two stories, perhaps somewhat related, about physicians unionizing to stand up to their new often managerialist overseers. The most prominent was in the New York Times on January 9, 2016, provocatively titled "Doctors Unionize to Resist the Medical Machine." It tells the story of how the hospitalists at PeaceHealth Sacred Heart Medical Center in Springfield, Oregon, formed a union de novo. The second started with a brief article in the Seattle Times on December 27, 2015, about how housestaff at the University of Washington (UW) revived a housestaff association and turned it into a union.

Managerialism as the Stimulus at PeaceHealth

The long article about PeaceHealth showed that managerialist leadership of the hospital system was the chief stimulus for unionization.

Managerialist Tactics: Outsourcing

The NYT article opened with

in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists, the hospital doctors who supervise patients’ care, to a management company that would become their employer.

The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.

Outsourcing is a now familiar entry in the managerialists' playbook. It is seen more in manufacturing than in health care. Although touted as improving economic "efficiency," it also may reduce the accountability of the managers of the organization that does the outsourcing.

Pursuit of Economic Efficiency

In this case,

Outsourced hospitalists tend to make as much or more money than those
that hospitals employ directly, typically in excess of $200,000 a year.
But the catch is that their compensation is often tied more directly to
the number of patients they see in a day — which the hospitalists at
Sacred Heart worried could be as many as 18 or 20, versus the 15 that
they and many other hospitalists contend should be the maximum.

It
was the idea that they could end up seeing more patients that prompted
outrage among the hospitalists at Sacred Heart, which has two facilities
in the area, with a total of nearly 450 beds. 'We’re doctors, we’re
professionals,' Dr. [Rajeev] Alexander said. 'Giving me a bonus for
seeing two more patients — I’m not sure I should be doing that. It’s not
safe.' (A hospital representative said patient safety was 'inviolate.')

A constant theme of managerialism, and the neoliberalism that underlies it, is economic efficiency. The usual narrative is that efficiency means providing better goods and services at lower costs. Instead, managerialism and neliberalism may mean decontenting goods and services so as to lower costs to the organizations providing them, but not necessarily providing more value to consumers. In health care terms, managerialism and neliberalism may lead to less accessible, more mediocre health care that increase revenue to the organizations providing it, as implied by the physicians' comments above. Making the US the most commercialized, managerialist run, and
arguably neoliberal health care system among the developed countries
has not led to lower costs, better access, or better health care
quality.

The backstory for the outsourcing emphasizes that managerialism, and the resulting economic efficiency was indeed the goal of PeaceHealth...

In 2012, Sacred Heart’s parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care. Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.

Centralization of Control

Furthermore,

The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.

'We’re trained to be leaders, but they treat us like assembly line workers,' said Dr. Brittany Ellison, a hospitalist in the group. 'You need that time with the patient,...'

A major feature of managerialism is the concentration of power within (generic) management. To quote Komesaroff(1),

In the workplace, the authority of management is intensified, and
behaviour that previously might have been regarded as bullying becomes
accepted good practice. The autonomous discretion of the professional is
undermined, and cuts in staff and increases in caseload occur without
democratic consultation of staff. Loyal long-term staff are dismissed
and often humiliated, and rigorous monitoring of the performance of the
remaining employees focuses on narrowly defined criteria relating to
attainment of financial targets, efficiency and effectiveness.

We're Only In It for the Money

Also, the negotiations that started once the PeaceHealth physicians formed their union demonstrated a central tenet of managerialism

Even starker than the divide over these questions are the differences
in worldview represented on opposite sides of the table. During a
bargaining session last fall, the administration proposed increasing the
number of shifts a year. Hospitalists now earn about $223,000 a year
for 173 shifts and are paid extra for working more. The hospital offered
$260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for
hitting certain medical performance targets. The hospitalists work
seven days on and seven days off, so this would have effectively
eliminated any time off for sick days or vacation.

When
the doctors pointed this out, the administration responded that if they
missed a few days, it would make sure they got extra days to hit the
required number of shifts for full pay.

The
hospitalists assured the administration negotiators that their concern
had nothing to do with money — that none of this had ever been about
money. They preferred to work less and make less to avoid burnout, which
was bad for them and worse for patients. At which point the
administration responded that money was always the issue, according to several people in the room. (The hospital declined to comment.)

Suddenly
it dawned on the doctors why they had failed to break through, Dr.
Alexander said. 'Imagine Mr. Burns,' the cartoonishly evil capitalist
from 'The Simpsons,' 'sitting across the table,' he said. 'There’s no
way we can say, 'This isn’t what we’re talking about. We’re not trying
to get the bonus.''

Again, managerialism is based on neoliberalism, and neoliberal view is that the market rules. The market is the arbiter of success, and money is the only outcome that matters. As Komesaroff put it(1),

The particular system of beliefs and practices defining the roles and
powers of managers in our present context is what is referred to as
managerialism. This is defined by two basic tenets: (i) that all social
organisations must conform to a single structure; and (ii) that the sole
regulatory principle is the market.

We
carry on the healing mission of Jesus Christ by promoting personal and
community health, relieving pain and suffering, and treating each person
in a loving and caring way.

Ostensibly, this is accompanied by core values, such as,

Stewardship
We
choose to serve the community and hold ourselves accountable to
exercise ethical and responsible stewardship in the allocation and
utilization of human, financial, and environmental resources.
and,

Social Justice
We build and evaluate the
structures of our organization and those of society to promote the just
distribution of health care resources.

We have frequently discussed how leadership of contemporary health care organizations often seem to act contrary to the organizations' stated mission, that is, mission-hostile management.

Value Extraction

Finally, while managerialism is ostensibly concerned with economic efficiency, whose efficiency matters. When managers address physicians' efficiency, they seem to look at
amount of work done divided by the cost to the hospital of paying
physicians. However, they never seem to look at their own costs, the
costs of management, as being a negative.

The PeaceHealth 2014 form 990,
the latest available, states that the then CEO, Mr Alan Yordy (whose
highest academic degree was an MBA, according to his LinkedIn page) had
total compensation in 2013 of $1,366,742, and 11 other managers had
total compensation greater than $250,000, with 9 having total
compensation greater than $500,000. Those figures should be compared to
the highest compensation offered the hospitalists, a maximum of
$280,000 for 182 shifts a year, eliminating all vacation and sick leave. So if it is all about the money, the managers are making the most of
it.

We have discussed ad nauseum the ridiculous compensation
of the leaders of health care organization, even non-profit
organizations. Value extraction by top management has become a central
feature of the US and global economy (look here).

The NYT article did not discuss whether the upset hospitalists knew about their bosses' compensation. I suspect they did.

Forming a Functioning Union at the University of Washington

The media coverage of the UW housestaff unionization was less detailed. It does appear, though, that a stimulus was the pursuit of economic efficiency by UW management through squeezing the pay of housestaff, as described in the December article in the Seattle Times. In it the house staff said,

they
account for about one-fifth of King County’s doctors and they want
higher pay, new child-care benefits and free parking. Some UW residents
and fellows earn so little that they qualify for welfare programs like
Temporary Assistance for Needy Families and the Seattle City Light
Utility Discount Program, according to the UWHA [University of
Washington Housestaff Association.]

The
association has proposed that residents and fellows earn at least the
same salary as the UW’s lowest-paid physician assistants. Because the
doctors in training work very long hours, they sometimes earn less than
Seattle’s minimum hourly wage, the UWHA has said.

The
council members, in their letter to Cauce, called the situation
shocking. And based on information from the UWHA, they wrote that some
residents and fellows qualify for welfare programs like Temporary
Assistance for Needy Families (TANF).

The Seattle
articles noted that the UW housestaff may earn from just over $53,000 to
just under $70,000 a year. Keep in mind, however, that under current
rules, house staff may work up to 80 hours a week. So $53,000 for
someone working those hours translates into $13.25/ hour, under what many
people now claim is the living wage. That could be considered exploitation of workers with doctoral degrees working in often
highly stressful situations where lives may be on the line. Whether there were issues other than money (and
the respect it implies) involved at UW was not apparent based on the
minimal press coverage.

So it appeared that the hospitalist physicians working for PeaceHealth, and most likely the housestaff of the University of Washington were pushed to unionize to counteract the managerialism of their hospital leaders.

The Results of Unionization So Far

In my humble opinion, similar stories to those at the PeaceHealth hospital about managers pushing physicians to increase productivity and efficiency, seemingly with little regard for the effect that might have on patient care and physicians' professionalism can be found at many hospitals and health systems. Housestaff may be paid at little more than minimum wage rates at many training institutions. However, employed physicians have rarely effectively resisted up to now. Perhaps one reason is that at many institutions, each employed physician has his or her own contract, and may feel little power to negotiate his or her working conditions independently. Housestaff physicians obviously might feel they have even less leverage. But at PeaceHealth Sacred Heart, the physicians had other ideas:

Amid the groaning, a relatively new member of the group named Dr. David Schwartz observed, 'They can’t fire all of us — there are unions.' This was a bit of a stretch: While there are hospitals around the country whose doctors are unionized, there did not appear to be a union anywhere composed of a single group of specialists. But Dr. Schwartz, a barrel-chested man with close-cropped hair and a bushy beard who would not look out of place at a graduate English seminar, thought unionizing might be worth a try.

At the time, it was only one of several options the doctors considered. They talked of forming an independent hospitalists group, of forming an alliance with an outsourcing firm of their choosing. But the alternatives gradually fell away for a variety of practical reasons, and the doctors were growing increasingly bitter.

Dr. Littell developed a riff, which the other hospitalists appropriated, about how the situation was like having your spouse of several decades announce he or she was going to play the field. 'You’ve been great, you’ve always been there,' he would joke. 'I just heard there could be better spouses out there.' The kicker: 'The good news is, you’re in the running, too!'

Amazingly, the unionization at PeaceHealth Sacred Heart was at least partially successful,

By March 2015, the PeaceHealth leadership, whatever its interest in efficiency gains, was apparently not pleased that one of its hospitals had a white-collar labor insurrection on its hands. The company announced that it would not outsource the hospitalists, a move it later said was always a possibility. Mr. Hill, who declined to comment, left in May.

The union did defeat the outsourcing tactic. But otherwise results have not been so quick to appear,

Noting that the negotiations with the hospital administration have dragged on for roughly a year, Dr. Schwartz said, 'It’s pretty obvious that they don’t want to get a contract done.' He says the administration worries that if it essentially rewards the hospitalists with a contract, it encourages other hospital workers to unionize too.

The housestaff at UW used a slightly different set of tactics, but still managed to form a real union. Per the earlier Seattle Times article,

Established in 1964, the UWHA was mostly dormant during the 1980s and 1990s, according to the association’s website. It became active again starting in 1999. In 2013, members proposed making it a state-recognized collective-bargaining unit.

The UW petitioned the state Public Employment Relations Commissionto block the move, arguing that the residents and fellows were students paid stipends rather than employees paid salaries. But the commission sided with the residents and fellows, who last year voted to unionize.

The housestaff association has succeeded in negotiating. But as did the PeaceHealth doctors, they have not yet been able to secure their positions, per the later article.

University of Washington brass say they’re committed to providing the UW’s medical residents and fellows with decent compensation and benefits, but they insist the newly unionized doctors in training are asking too much in contract negotiations.

So,

Talks have been stalled for some time but are set to resume this month with a mediator assigned by the state Public Employment Relations Commission.

The two sides 'remain far apart in the area of compensation,' Joyner wrote in his letter.

Parenthetically, unexplored in any of the press coverage is whether the parallels between what is going on at PeaceHealth and the University of Washington have to do with explicit ties between the organizations. In 2013, per Beckers' Hospital Review, the news broke that the two institutions signed a letter of intent to create a "strategic alliance." In 2014, an article in the Seattle Times noted the ongoing concerns of housestaff and students at UW that the alliance could be diminishing their educational opportunities.

Summary

In one sense, it is amazing that physicians are now starting to unionize as a response to the managerialism of their leaders. It was not all that long ago when the majority of physicians worked as solo practitioners or in small group practices, and fiercely defended their autonomy. The last thing they would have thought about was unionization. Since physicians were their own bosses, with whom could their unions have negotiated? In addition, in the US, independent physicians and physician practices could not legally unionize. Practices that discussed such issues as fees were liable to anti-trust prosecution. And with what bosses could they have conceivably negotiated.

Yet now physicians are increasingly corporate employees, hence corporate physicians. At the moment, unionizing may be one of the few effective tactics health care professionals can use to halt the march of managerialism/ generic management and partially relieve the plight of the corporate physician (and health care professional.) However, in the long run, as long as people who care more about money than about patients' and the public's health run health care, even unions will not be able to make that much progress, and not without adverse effects.

It would take true health care reform to address the larger problems with health care and society that is now leading to physicians unionizing. In my humble opinion, hospitals, health care systems, and other "provider organizations" should seek better patient care, not growth. Should they not voluntarily downsize (an almost comical idea in the current context), anti-trust enforcement, and probably new legislation would be needed to stop their pursuit of market dominance and return them to responsible community organizations. The now much smaller hospitals, and provider organizations should not be run for profit, and the commercial practice of medicine should again be illegal. Most physicians should go back to being private practitioners as individuals or within small groups. Leaders of hospitals and provider organizations should be accountable for putting patients' and the public's health first, upholding professional values, and should not expect to get rich doing so. But I dream on....

Musical Interlude

To lighten things up, if only a little, here is the YouTube video version of the full third album by the Mothers of Invention, led by the incomparable Frank Zappa, "We're Only In It for the Money."

Behind all hospitals are nationally organized attorneys who know how to defeat, delay, and twist lowly physician negotiators at the bargaining table. They have been doing it for years quashing any physician embers of hope we have to bring sanity back to our healthcare system.

The largest group of doctors in this country were private practitioners. But as in the article, they could not legally organize into unions. Physician groups like state associations and the AMA were diluted by egos, profits, and manipulation while rendered useless as leaders.

Now doctors have the tatterings of what is left as they lay on the mat for the 10 count. I do not foresee us amounting a response without the public rising up and acknowledging the profit motives as a barrier to better healthcare.

The results of hospital administrative greed are seen everyday throughout our country blatantly in the view of doctors. We need an organized group of physicians to write whistleblowing stories for the public to help us off the mat.

Organizing doctors is “like herding cats.” It won’t happen unless a few of us (possibly through Health Care Renewal) can raise the ire of public opinion against this threat.

As Dr. Poses has pointed out through a quote of Martin Luther King Jr.: “The ultimate tragedy in not the oppression and cruelty by the bad people but the silence over that by the good people.”

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